Justia Insurance Law Opinion Summaries

Plaintiff, suing on behalf of her husband, obtained a judgment against defendant for benefits payable under a home health care insurance policy. Defendant appealed and following a judgment, the district court awarded plaintiff attorney's fees and costs. Defendant again appealed. The court held that the district court properly granted summary judgment to plaintiff, rejecting defendant's contention that the custodial care expenses claimed were not covered expenses under the policy. Case No. 10-15115 was affirmed. Because defendant challenged the award of attorneys' fees and costs in Case No. 10-15878 on the sole ground that summary judgment was improperly granted in Case No. 10-15115, the award of attorneys' fees and costs in Case No. 10-15878 was affirmed.

This case involved Commonwealth Care, a state-initiated program that provided structured premium assistance for low-income Massachusetts residents. In 2009, the Legislature made certain changes to the eligibility requirements of Commonwealth Care, enacted in a two-part supplemental appropriation for fiscal year 2010. Section 31(a) of the appropriation excluded all aliens who were federally ineligible under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), 8 U.S.C. 1601-1646, from participation in Commonwealth Care. Plaintiffs were individuals who either have been terminated from Commonwealth Care or have been denied eligibility solely as a result of their alienage. The court held that section 31(a) could not pass strict scrutiny and that the discrimination against legal immigrants that its limiting language embodied violated their rights to equal protection under the Massachusetts Constitution.

This lawsuit arose from an insurance contract between Plaintiff, who had cancer, and Defendants, two insurance companies. In May 2007, Plaintiff applied for long-term care benefits under her policy. Defendants found her eligible for benefits and paid her caregiver for services beginning in October 2007. Defendants provided coverage for Plaintiff for almost a year, then terminated her benefits on August 25, 2008. Nearly five months later, on January 23, 2009, Defendants reinstated her benefits retroactively. After Defendants terminated Plaintiff's benefits, she attempted suicide. On July 9, 2009, Plaintiff sued Defendants, alleging, inter alia, insurer bad faith and negligent and intentional infliction of emotional distress. The Supreme Court subsequently accepted a question certified to it by the district court and answered it by holding that if a first-party insurer commits bad faith, an insured need not prove the insured suffered economic or physical loss caused by the bad faith in order to recover emotional distress damages caused by the bad faith.

Respondent, an insurer/managed care organization, contracted with an endoscopy center and gastroenterology center (collectively, the Clinic) to provide health care services to its insureds. After the Nevada Health District found that the Clinic engaged in a number of unsafe medical practices, Respondent terminated its contract with the Clinic. Janice Munda was insured by Respondent through her employer's health plan, which was governed by ERISA. Munda was diagnosed with hepatitis C, which the Health District determined she contracted as a result of being treated at the Clinic. Janise and her husband (collectively, Appellants) sued Respondent for negligence, negligence per se, breach of implied covenant of good faith and fair dealing, and loss of consortium. The district court granted Respondent's motion to dismiss, finding that Appellants' claims were preempted by ERISA. The Supreme Court reversed, holding that under the facts, there was no preemption because Respondent's alleged actions were independent of the administration of the ERISA plan.

Employee received workers' compensation benefits for a neck and back injury he suffered in 2002 while working for Employer. After his benefits were discontinued in 2004, Employee sought treatment for a low back condition and petitioned the Department of Labor for workers' compensation benefits. The Department denied the petition, ruling that Employee did not prove his low back condition was related to his original 2002 work injury. The circuit court affirmed. The Supreme Court affirmed, holding that the Department correctly denied workers' compensation benefits where Employee failed to establish by a preponderance of the evidence that the 2002 injury was a major contributing cause of his current low back condition.

Blue Cross and Blue Shield of Montana (BCBS) and New West Health Services (collectively TPAs) administered a self-funded employee healthcare benefit plan for the State's employees. Jeannette Diaz and Leah Hoffmann-Bernhardt (Plaintiffs), who were both injured in accidents, filed suit against the state, BCBS, and New West for allegedly violating their made-whole rights by failing to conduct a made-whole analysis before exercising subrogation rights. Plaintiffs moved for class certification seeking to include in the lawsuit individuals who had their benefits reduced under the State plan, as well as individuals who had their benefits reduced under policies independently issued and administered by the TPAs. The district court denied class certification and determined that Montana's made-whole laws did not apply to TPAs. The Supreme Court (1) affirmed the district court's finding that BCBS and New West, in their capacities as TPAs in the present case, were not subject to the made-whole laws under either the subrogation statutes or under a third-party beneficiary theory; and (2) reversed the district court denial of class certification, as Diaz and Hoffmann-Bernhardt demonstrated that the requirements of Mont. R. Civ. P. 23 were met.

Appellant Indiana Spine Group provided medical services to employees of various businesses for injuries the employees sustained arising out of and during the course of their employment. The employers authorized the services and made partial payments. In each case, more than two years after the last payments were made to the injured employee, Appellant filed with the worker's compensation board an application for adjustment of claim seeking the balance of payments. The Board dismissed the applications as untimely. In each case the court of appeals reversed and remanded. At issue on appeal was what limitation period was applicable to a medical provider's claim seeking payment of outstanding bills for authorized treatment to an employer's employee when the Worker's Compensation Act was silent on the question. The Supreme Court reversed the Board, holding (1) the limitation period contained in the general statute of limitation enumerated in Ind. Code 34-11-1-2 controlled; and (2) because Appellant's claim was timely under the statute, the Board erred by dismissing Appellant's application.

Plaintiff, the personal representative of the Estate of Gaye S. Glaser, appealed the district court's affirmance of the Medicare Appeals Council's (MAC) ruling that Kaiser was not required to pay for Glaser's liver surgery. Plaintiff contended that by refusing to cover the procedure, Kaiser failed to comply with 42 C.F.R. 422.112(a)(3), which required Medicare Advantage plans to make their services available, accessible, and adequate, and 42 C.F.R. 422.112(a)(9) and 422.113(b)(iii), which required the plans to cover "urgently needed services." The court held that substantial evidence supported the MAC's decision and affirmed the judgment.

Appellant Margerita Cervantes allegedly contracted hepatitis C as a result of treatment she received at the Endoscopy Center of Southern Nevada (ECSN). Appellant obtained treatment at ECSN as part of the health care benefits she received through her culinary union. The union operated a self-funded ERISA health care plan and retained Respondents, Health Plan of Nevada and other health and life insurance entities, as its agents to assist in establishing a network of the plan's chosen medical provider. Appellant filed a lawsuit alleging that Respondents were responsible for her injuries because they failed to ensure the quality of care provided by ECSN and referred her to a blatantly unsafe medical provider. The district court concluded that Cervantes' claims were preempted by ERISA section 514(a). The Supreme Court affirmed, holding that state law claims of negligence and negligence per se against a managed care organization contracted by an ERISA plan to facilitate the development of the ERISA plan's network of health care providers were precluded by ERISA section 514.

Respondent brought this action against appellant to compel payment of no-fault benefits in the amount of its bill, plus statutory interest and attorney's fees, alleging that it had provided timely notice and proof of claim under 11 NYCRR 65-1.1, which required an insured person's assignee to submit written proof of claim no later than 45 days after the date health care services were rendered. At issue was whether a health care services provider, as assignee of a person injured in a motor vehicle accident, could recover no-fault benefits by timely submitting the required proof of claim after the 30-day period for providing written notice of the accident had expired. The court held that the submission of the proof of claim within 45 days of the date health care services were rendered could not serve as timely written notice of accident after the 30-day period for providing such written notice had expired.